Comparing Narrow Diameter Implant Systems:

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1 Comparing Narrow Diameter Implant Systems: Which is best suited for your practice? Dr. Peter A. Karsant DDS 1601 Alemany Blvd. San Francisco, CA

2 Curriculum Vitae Graduated University of the Pacific Dugoni School of Dentistry 1982 Member AAE Present Alumni of UOP s Dr. Larry Lum Implant Study Club Hands-on Live Patient Training Advanced Implant Study Club Patient Care Committee Board Member Physians Reinbursment Fund 2008-Present Occurance Coverage Board Member Opt-In Dental Group 2014-Present Expert Witness / Case Reviewer Dental Board of California 1994-Present Clinical Professor PreClinical Removable at UOP

3 Many Thanks Dr. Gene Labarre & Dr. Dennis Shinbori

4 Disclosures I maintain a full-time practice. I am not an employee of any manufacturer mentioned within this presentation. I have used all products mentioned in this presentation. All restorations are made by my in-house lab: GEOFFREY S DENTAL LAB

5 Everything is theoretically impossible UNTIL IT IS DONE. -Robert A Heinlein

6 Implant Classification Transitional 1.8mm or less Narrow mm Conventional mm Wide 6.0mm and larger

7 Units To Remember 150 Nmm =15 Ncm 1 Ncm =.089 lbs 70 Ncm = 6.2 lbs 20 Ncm = 1.77 lbs

8 What Are Narrow Diameter Implants? Under 3.0mm in diameter TiAl6V4 alloy Single piece construction Textured or etched on integrating surface Immediate Loading O-ball abutment denture Tapering cylinder cemented crown/bridge Screw-retained abutment variety

9 Applications Overdenture full or partial Single tooth restorations congenitally missing laterals, converging roots, limited interdental space Multi-unit bridges thin ridges Immediate temporization emergency repairs, protection of grafted sites, surgical guide stabilization, tissue architecture, orthodontic anchorage

10 Financial Aspects Narrow diameter implants range in cost $70 - $145 per fixture. Total cost per case for overdenture varies from $450 - $820. Implant handpiece is useful but you can use a slow speed air turbine with latch C/A. To determine fees: 4 implant overdenture = 2-3x (where x is the cost of new denture)

11 Advantages Apply less invasive surgical procedures when there is circumferential bone deficiency Placed in reduced interradicular spaces (ie: mandibular incisors) Olate et al 2010; Elsyad et al 2011

12 Considerations Independent studies can generally be trusted Be cautious of company-specific supported studies

13 When Choosing a System Get excellent training Hands-on models Live Surgery Train your staff Narrow diameter implants are implants!

14 Patients Perceive Improvement In all aspects of their life (eating, speaking, comfort), patients should perceive improvement regardless of implant diameter.

15 Does Shape Matter? Atlas -Dentatus MDI 3M ESPE (formerly IMTEC)

16 Will the system you choose accomplish all things for all patients, or just some things for some patients?

17 Ask Yourself Does the system allow for crown & bridge work? Can you convert a patient from a removable option to a fixed and vice versa? Will it be compatible with my conventional implant system?

18 Will it be cost effective, easy to use & more importantly is the system easy to navigate?

19 Lab Considerations Success requires quality work and communication. Has your lab worked with the system before? If not, it should be easy enough to guide them through the process. Labs should not charge more for narrow diameter implants.

20 Yes, They Integrate! Histology reports indicate 81.3% bone to implant interface at 18 months when immediately loaded. Narrow diameter implants are made of the same Ti-Alloy as conventional sized implants. The bone does not know the difference between a 1mm implant or a 9mm implant. Dr. Dennis Tarnow

21 Peer Reviewed Studies Histological evaluation of immediately loaded transitional implants after 18 months reveal 81.3% bone to implant contact of the surface evaluated. Proussaefs DDS, Loma Linda Univ Journal of Prosthetic Dentistry April 2003,

22 The mean follow up period for all implants was 48 months. Only one implant was lost, yielding survival rates of 98.9% Anitua, E et al. Clinical Evaluation of mm NDIs as Definitive Implants in Different Clinical Situations: A Retrospective Cohort Study Euro Journal of Oral Implantology Winter.

23 Dentures supported by Dentatus Atlas implants provided immediate occlusal loading and function with a high survival rate of implants (94.1%) and patient satisfaction (100%). Tai CH, Lee MC, Saito H, Classi A, Cho S-C, Froum S, Elian N, Tarnow D., "Immediate Loading of Narrow Diameter Implants with Overdentures in Severely Atrophic Mandibles: Practical Procedures & Aesthetic Dentistry, April 2007, Vol. 19, No. 3

24 At UOP approximately 1500 mini implants have been placed since 1998, and the cumulative failure rate was less than 10%.

25 A report by Bulard and Vance in the December 2005 issue of Compendium, with over 1,000 mini implants, stated a failure rate of slightly less than 10%.

26 Gordon Christensen now recommends mini implants as safe, easy and effective for lower denture retention, which is powerful testimony to the widening acceptance of mini implants by the dental profession.

27 Survival Rates In summary: Similar to conventional implants Majority of studies report % No study reports less than 89% In my practice survival at 5 years for fixed or removable is 98%

28 McGill Consensus In 2002, an International symposium at McGill University concluded that the implant retained overdenture should become the first-choice prosthodontic treatment for patients with edentulous mandibles.

29 3M ESPE - MDI O-ball design for lower denture retention *3M will discontinue the manufacture and sale of the MDI Mini Dental Implant product line on September 1, 2016.

30 MDI placed 2006

31 MDI placed 2009

32 MDI Advantages Easy to use with training Retention is good over time O-rings are easy to change As good as any o-ball system BAD NEWS: 3M has discontinued product line

33 What Do Patients Think?

34 Zest - LODI Introduced to market: Nov 2012

35 LODI Advantages Easy to use with training Retentive element is long-lasting Retentive element is adjustable DISADVANTAGE: implant requires 70Ncm of torque for immediate loading

36 Dentatus Narrow Diameter Implants Dentatus ANEW: Screw-retained system Introduced 1999 Atlas Denture Comfort with Tuf-Link Silicone Introduced 2002 MTI-Monorail Transitional Implant Introduced 1993

37 Dentatus ANEW Features Versatile threaded connector Anti-rotational platform Texturized threaded surface Tapered, self-threading apical end Available in 3 diameters & 3 lengths

38 Restorative Components CROWN SCREW-CAPS BLACK, WHITE or TITANIUM SINGLE TOOTH RESIN or TITANIUM

39 Restorative Components BRIDGE SCREW-CAPS BLACK, WHITE or TITANIUM MULTI-UNIT TITANIUM

40 Restorative Components DENTURE RETENTION ELYPSE RESIN or TITANIUM with Tuf-Link Silicone

41 Restorative Components IMPRESSION ASSEMBLY SCREW-CAP PLUG BRASS CLOSED TRAY IMPRESSION SCREW-CAPS sent to lab with Castable Coping for BLACK FINAL RESTORATION IMPRESSION RESIN

42 Atlas Denture Comfort One-piece implant 3mm dome-shaped head Dentatus ANEW with Elypse Smooth biological width Texturized threaded surface Available in 4 diameters & 3 lengths

43 What Do Patients Think?

44 The King & His Dentures Excellent denture techniques are a MUST in attachment dentistry

45 Custom Teeth

46 Dentures With Custom Teeth

47 Diagnosis Candidates for narrow diameter implants include: Medically compromised Elderly demanding shorter treatment times Anyone who opts out of grafting Patients with limited interdental space

48 Treatment Planning Panoramic x-ray or icat for guided surgery Diagnostic wax-up a MUST for cases involving 3+ implants In-office surgical guide (suck-down stent) Processed temporaries (chairside may also be fabricated) Diagnose the entire mouth not just the implant site Partner with an excellent lab with experience

49 Case Presentation Guided Surgery 2010

50 Surgical Guide

51 Surgical Guide

52 Immediate Splinted Temps

53 Transfer Coping

54 Custom Abutments

55 Abutments Placed

56 Cemented Crowns

57 Protocols for Success Pre-Surgical diagnosis is a MUST Hands-on Training (through the restorative phase) Models Live Patients

58 Evaluate the Denture Are the teeth worn? Does the denture need a reline? Are the extensions adequate? Do they rock A/P? Are they in centric relation?

59 Fixed Restorations Molar Restoration Allow 3 months integration Bicuspid to Biscuspid Single Implants Immediate temporary out of occlusion or allow 3 months for integration Multiple Implants Immediate splinted temporary out of occlusion or allow 3 months for integration

60 Overdentures Chlorhexidine rinse for 1 min Check that any necessary premeds have been taken Anterior mandibular implants may be loaded immediately if you achieve 20Ncm torque for o-ball & Elypse heads For LODI implants, 70Ncm torque If torque is not reached a soft liner should be used for 3 months to allow integration.

61 How Many NDI s Should You Place? Most manufacturer s recommend a minimum of 4 in the mandible 10mm LaBarre s Rule Large: 10mm spacing Medium: 8mm spacing Small: 6mm spacing

62 The limits of the impossible can only be defined by going beyond them, into the impossible. -A C Clark

63 Which NDI Do I Choose? 3M MDI discontinuing product Zest LODI only for removable overdentures Dentatus ANEW interchangeable heads for single crown, bridge or overdenture

64 Dentatus ANEW Routine crown and bridge work for your lab Solid models with removable analog Soft tissue models in esthetic zone Custom abutments, similar to cast cores

65 MAXILLARY OR MANDIBULAR WITH PROPER PLANNING

66 CANNINE TO CANINE TEMPORARY CROWNS MUST BE OUT OF OCCLUSION

67 POSTERIOR ANEWS MUST BE ALLOWED TO INTEGRATE

68 Overdentures

69 Bridge Work, 2008

70 2009, Bridge 7-10

71 2010

72 ANEW Placed & Splinted

73 Processed Custom Stained Temp

74 Patient & Temporary

75 ANEW Can Be Used with Conventional Implants

76 ANEW Can Save A Case

77 Steps for Fixed Prosthetics Diagnose entire mouth Mount study models with facebow Diagnostically wax the case Duplicate the case for processed temporaries and surgical guide Place the Dentatus ANEW Implants and let them integrate Take final impression for custom abutment and crown Deliver the case

78 DIAGNOSE, MOUNT, DUPLICATE,SURGICAL GUIDE

79 PLACE ANEWS, LET INTEGRATE,FINAL IMPRESSIONS

80 LAB WORK

81 DELIVER THE CASE

82 Case Presentation: Lower Incisors Step-by-step from temporary to final restoration

83 Implant on Healing

84 Modified Impression Post

85 Impression & Removable Analog

86 Castable Resin Coping

87 Abutment Seating

88 Crown Placement

89 Case Presentation: Elderly Patients 91 y.o. with natural dentition

90 Diagnostically Waxed & Temporary Made The Temporary is used as a Surgical Guide Indelible Pencil marks the tissue for the posterior ANEW

91 Tissue Marked for Placement Use 8 round burr to open tissue to bone Make osteotomy Place implants

92 Implant Placement

93 Processed Temporary

94 3 Mos Later: Final Impression

95 5 Years In Function

96 Case Presentation: Replacing a Bicuspid 85 year old female Lost bicuspid to vertical fracture. The area was allowed to heal post extraction for 3 months (1 bone cycle) before placement of the ANEW which was buried for 3 months of healing. Impressions were taken and the ANEW was restored.

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98 Osteotomy

99 Implant Seating

100 Healing Collar: 3 Months

101 Uncovering & Impression

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104 Final Restoration

105 Case Presentation: Replacing Centrals

106 Stent

107 Implant Placement Ncm is ideal

108 Temporaries Over contoured, splinted temps promote papillae formation during healing

109 Impression

110 Master Cast

111 Custom Cores

112 6 Years in Function

113 Logic will get you from A to Z, IMAGINATION WILL GET YOU EVERYWHERE - A. Einstein

114 Case Presentation: A Vision for the Future

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119 Opportunities are never lost because someone will always find them.

120 Reinvest in your Education Get excellent NDI training on models and live patients Learn to do excellent basic endo, perio and oral surgery Update your skills in dentures Be able to survey and design Find a lab that delivers quality without compromise

121 Advantages of ANEW Can be used in maxilla or mandible Removable or Fixed Restorations You can even transition from one to another Easy to place Easy to restore Cost effective for both doctor and patient

122 - Take Home Notes for Review Mounted study models in conjunction with radiographs (panoramic) are generally all that is needed for a denture case Mounted models that are diagnostically waxed and duplicated for a surgical guide (suck down stent) and processed temporaries or chairside temporaries for fixed prosthetics Fixed temporaries must be out of occlusion for healing

123 - Take Home Notes for Review A minimally invasive technique is advised when the ridge is 4mm+ B-L: Local anesthetic is infiltrated locally (for FLD ½ carp Septocaine B&L over each site; for fixed anesthetize as you normally would) The patient is asked to rinse the mouth with chlorhexidine solution for 60 seconds (on a general basis, systemic antibiotics are not necessary) The number of implants to be placed is determined via LaBarre s rule The areas in which the implants will be placed are marked with an indelible marker A number 8 high speed round burr is used to open the tissue to bone A pilot twist drill is used at slow rotation ( RPM for Dentatus; for Zest and for 3M) and with copious sterile irrigant to create a pilot hole through the soft tissue A flap is usually not created for mini implants

124 - Take Home Notes for Review The implant is threaded into the pilot opening by a series of hand wrenches. As it engages the bone, the larger diameter of the implant compresses the bone and creates resistance to torque. The screw portion of the fixture is self-threading in cancellous bone. If the torque resistance becomes too great to proceed, the implant is removed and the drill is reintroduced to enlarge or deepen the site. If the torque resistance remains minimal, or if the implant threads strip the bone, a wider and/or longer implant can be tried. Alternatively, a new site can be attempted at least 2 mm distant from the original site. The implant is rotated to place until all of the threads are embedded in bone and the head projects from the tissue by a suitable amount. In the event of a sharp ridge crest, or in those cases where natural teeth have been extracted at the same appointment, it is necessary to reflect a soft tissue flap in order to flatten the alveolar process before placing the implants into the optimized sites. After placement of the implants, the prosthesis is fabricated or relined to make immediate use of the implant

125 - Take Home Notes for Review The most useful radiograph for planning mini-implants in the anterior mandible is the Panorex. In situations where ridge is undercut or narrow, I recommend a lateral ceph and an occlusal view of the anterior mandible. The Panorex demonstrates mandibular height and bone density. The lateral ceph shows the buccolingual cross sectional shape, which determines angulation of the fixtures near the midline. Tomograms and other computerized radiography are the gold standard, but represent a substantial expense for mini-implants in the anterior mandible.

126 Special Thanks The cases presented were constructed by Geoffrey s Dental Lab San Francisco, CA Quality without Compromise

127 Dr. Peter A. Karsant DDS 1601 Alemany Blvd. San Francisco, CA